Appendix C
Descriptions of Summit Communities

ASTHMA COMMUNITIES

Children’s Mercy Hospital/Kansas City Asthma Coalition

Children’s Mercy Hospital (CMH) has developed an asthma registry with the goal of combining information from multiple sources to reduce fragmentation of care. Its disease management program includes an intensive asthma education program with 8 weeks of training on site in private physicians’ offices—reimbursed by some health plans once the intervention has been completed, followed by ongoing support for asthma management. A complete culture change in health care delivery directed toward patient empowerment and self-management using a multidisciplinary team is emphasized. Home visits are conducted using technologies such as air sampling to optimize asthma treatment. Plans for an asthma coalition with multiple stakeholders are in progress, with the goal of identifying and efficiently allocating asthma resources where they are needed. CMH is one of six recipients nationwide of Improving Asthma Care for Children grants from The Robert Wood Johnson Foundation, which target children with asthma covered by Medicaid and State Children’s Health Insurance Programs.



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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Appendix C Descriptions of Summit Communities ASTHMA COMMUNITIES Children’s Mercy Hospital/Kansas City Asthma Coalition Children’s Mercy Hospital (CMH) has developed an asthma registry with the goal of combining information from multiple sources to reduce fragmentation of care. Its disease management program includes an intensive asthma education program with 8 weeks of training on site in private physicians’ offices—reimbursed by some health plans once the intervention has been completed, followed by ongoing support for asthma management. A complete culture change in health care delivery directed toward patient empowerment and self-management using a multidisciplinary team is emphasized. Home visits are conducted using technologies such as air sampling to optimize asthma treatment. Plans for an asthma coalition with multiple stakeholders are in progress, with the goal of identifying and efficiently allocating asthma resources where they are needed. CMH is one of six recipients nationwide of Improving Asthma Care for Children grants from The Robert Wood Johnson Foundation, which target children with asthma covered by Medicaid and State Children’s Health Insurance Programs.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Controlling Asthma in the Richmond Metropolitan Area Initiated in 2001, Controlling Asthma in the Richmond Metropolitan Area (CARMA) is one of seven initiatives selected for the Controlling Asthma in American Cities Project, funded by the Centers for Disease Control and Prevention. This project targets children aged 2–18 and their families, using community-based interventions that include education, intensive case management for high-risk children, and health care provider education. Project efforts include managed care collaboration and parish nurse/lay outreach partnerships. Also, linkages between obesity and asthma are being explored. The Bon Secours Richmond Health System, the University of Virginia Health System, and the Central Virginia Asthma Coalition are partners in this initiative, which includes annual assessments of effectiveness, cost, collaborative relationships, and feasibility of expansion. Long-term outcomes will be assessed by tracking hospitalizations and emergency department visits. The Pediatric/Adult Asthma Coalition of New Jersey The Pediatric/Adult Asthma Coalition of New Jersey (PACNJ), sponsored by the American Lung Association of New Jersey, is a state-level consumer-driven initiative formed in 2000 to provide the state with a clearinghouse for asthma programs and services. It currently uses six task forces to ensure that all public and private educational and child care facilities, physicians, and other providers comply with the National Heart, Lung, and Blood Guidelines for asthma management. PACNJ has been involved in the development of a state-mandated asthma action plan for any child carrying an inhaler in school and has provided school nurse education, with pre- and post-tests, via satellite broadcast. Its health insurance task force has developed guidelines for standards of care related to asthma treatment, based on findings from a conference on best practices for public and private New Jersey insurers. Current projects are focused on patient self-management tools for recognizing asthma severity and controlling asthma triggers in the home and school. Philadelphia Department of Health The Philadelphia Department of Health is one of 12 recipients nationwide of the Department of Health and Human Services’ Steps to a HealthierUS grant. This initiative supports community-based programs designed “to help Americans live longer, better, and healthier lives” by reducing the burden of asthma, diabetes, and obesity. Steps funding will enhance programs already under way in Philadelphia, such as an asthma call center (Child Asthma Link Line) that links children who have presented at local pediatric emergency departments with acute asthma exacerbations to specialists and other community resources, such as asthma self-management education programs and programs to eliminate home environmental triggers. Future plans are to expand this care coordination model to other chronic diseases, starting with diabetes. The Asthma Call Center was established in partnership with the Philadelphia Allies Against Asthma Coalition and is funded by a grant from The Robert Wood Johnson Foundation. DEPRESSION COMMUNITIES Intermountain Health Care—Depression in Primary Care Initiative Intermountain Health Care (IHC)—an integrated delivery system that includes providers, plans and hospitals—has focused on management of depression in primary care settings within the framework of the Chronic Care Model. This initiative provides the primary care clinician, patient, and family with the tools and organizational supports needed to identify, diagnose, treat, and manage depression. The effort, begun in 1999, has

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities improved patient functional status and outcomes and enhanced physician satisfaction, and has not raised costs for employers or plans. In association with its community partners, IHC has developed an implementation plan for the delivery of evidence-based depression treatment in the primary care setting through a Mental Health Integration (MHI) model. As one of eight Robert Wood Johnson–funded Incentive Grant national sites for linking clinical improvement to economic strategies for depression care, this demonstration project includes a sustainable business plan that aims to link financial value to the delivery of improved clinical outcomes. Currently, the IHC initiative involves seven internal and eight community groups. By 2005, IHC hopes that a sustainable business model based on this community partnership effort will be fully implemented in 20 clinic sites, involving 85 physicians and more than 490,000 annual client visits. Mid-America Coalition on Health Care Community Initiative on Depression In 1998, the Mid-America Coalition on Health Care collaborated with eight Kansas City employers with the aim of identifing health risks to employees and their families. The Behavioral Risk Factor Surveillance System (BRFSS) was administered to a representative sample of 45,000 area residents, and the results were compared with Healthy People 2010 benchmarks. The group agreed to target depression in order to focus on creating community support for timely diagnosis and treatment, destigmatization, and identification of direct and indirect costs associated with the disorder. After an initial focus on designing the initiative and introducing it to regional employers, health plans, and physicians, the coalition has expanded to 15 employers and tripled the number of individuals impacted. Now in phase II, the coalition is studying barriers to diagnosis and treatment and best practices in benefit design, as well as supporting worksite educational programs and facilitating multidisciplinary communication. In phase III, increased community involvement through churches, schools, and health departments will expand the coalition’s scope and enable redistribution and analysis of the BRFSS. The entire project will be documented to encourage duplication of regional collaboration for improving the community’s health. DIABETES COMMUNITIES County of Santa Cruz, California Santa Cruz County, California, a blend of urban and rural communities with a population of 260,000, faces the challenge of diabetes across all sectors of health care. A growing Latino population with a disproportionate prevalence of type 2 diabetes intensifies concern regarding the overall increase in this disorder. Two competing private medical groups and the Medi-Cal managed care program have joined the public health department in two collaborative approaches. The first, the Regional Diabetes Collaborative (RDC), has brought together front-line professionals from all disciplines and all sectors from three contiguous counties to create a coordinated approach to diabetes treatment, patient education, and policy advocacy. At the same time, an executive-level collaborative, the Santa Cruz Health Improvement Partnership (HIP), has selected common-ground issues that affect all health care interests, bridging silos and opening gates in competitive fences. HIP has chosen diabetes for its 2004 communitywide target, harmonizing its efforts with those of RDC. The vision for this effort involves preventive approaches to diabetes beginning in childhood, extending through guideline-driven, consistent care for diagnosed individuals using communitywide systems of care.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities The Asheville Project The Asheville Project began in 1997 as a collaborative effort involving Mission-St. Joseph’s Hospitals; the City of Asheville, North Carolina; the North Carolina Association of Pharmacists; and the University of North Carolina. It focused initially on improving diabetes care for 47 Asheville city employees. The key elements of the program are financial incentives (waived medication copayments) to encourage patient participation, intense self-care education, and frequent one-on-one monitoring/ assessment of patients by a care manager. Each patient’s care is compared with guideline standards, and success is assessed frequently according to these standards. Collaborative goals are established, barriers identified, questions answered, and recommendations made to the patient’s physician. Active participation qualifies patients for medication copay waivers, education is covered, care managers are paid, physicians are provided guideline recommendations on individual patients, and the health plan receives a positive return on investment. The project has resulted in annual net savings for 164 patients of $2,033/ person/year for 5 years, a 50 percent reduction in sick days, increased patient self-testing from 70 to 99 percent, and significant improvement in clinical parameters. Today, 300 patients with diabetes are involved in the project, with another 400 patients in programs managing asthma, hypertension, and hyperlipidemia. Twelve other communities are replicating the Asheville Project. Madigan Army Medical Center Madigan Army Medical Center (MAMC) is an academic referral center that supports all Department of Defense direct health care and the TRICARE program, covering tertiary care for 460,000 beneficiaries in Washington, Oregon, and Alaska. Of the 103,000 beneficiaries who reside in the community served by MAMC, 76,000 are enrolled for primary care, including 3,000 individuals with adult-onset diabetes. MAMC’s diabetes initiative uses an electronic scorecard keyed to evidence-based Diabetes Quality Improvement Project (DQIP) parameters, provider performance reports, and interactive patient surveys to facilitate care decisions, clinician teamwork, and patient engagement. Successful outcomes for this diabetic population include a 41 percent decrease in emergency department visits, a 16 percent decrease in bed days, and annual savings of $0.3 million. The Washington State Diabetes Collaborative The Washington State Diabetes Collaborative was established in 1999 to address the findings of a statewide project that identified significant gaps between existing and desirable diabetes care. Based on the Institute for Healthcare Improvement's Breakthrough Series approach, the collaborative has engaged more than 65 teams from urban and rural, public and private, and small to large care delivery systems and health plans in improving the delivery of patient-centered diabetes care. The collaborative is sponsored by Qualis Health, the Washington State Department of Health (DOH), and The Robert Wood Johnson Foundation–funded Improving Chronic Illness Care Program of the Sandy MacColl Institute. Qualis Health, a Seattle-based private, nonprofit organization, provides a broad range of services to consumers, employers, providers, managed care organizations, and government agencies aimed at improving the quality of health care delivery and health outcomes. It serves as the Medicare Quality Improvement Organization for Washington. The Washington DOH works to protect and improve the health of the people of Washington. The DOH Diabetes Prevention and Control Program supports this mission by improving the health care delivery system, enhancing health communications, and building active health communities.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities HEART FAILURE COMMUNITIES Grand Rapids Medical Education and Research Center The Medical Education and Research Center (MERC), a consortium of health systems, health plans, the educational community, and other groups in Grand Rapids, Michigan, is dedicated to community improvement and education. Leaders involved in the MERC consortium meet twice monthly to discuss quality and health improvement initiatives. MERC’s current efforts include a focus on care coordination, with an emphasis on improving patient flow across the community’s entire health system, which builds upon a module in the Institute for Healthcare Improvement’s Impact Program. Other efforts under way include collaboration on population-focused disease management, financial incentives at the physician level that have been targeting quality benchmarks since 1997, and placement of interdisciplinary “learner teams” that partner with neighborhood associations and parish nursing programs to conduct community health assessments and develop focused interventions. MERC also has dedicated staff who design and implement evaluations of each of these interventions. Greater Flint Health Coalition Established in 1992, the Greater Flint Health Coalition (GFHC) is a community/institutional partnership and a multifaceted collaboration involving government, hospitals, labor, business, insurers, physicians, educational systems, consumers, and faith-based organizations in Flint, Michigan. The United Auto Workers and General Motors joined GFHC in 1994, leading to the development of community-based initiatives focused on treatment and prevention of heart disease, diabetes, and depression and other health needs. The Guidelines Applied in Practice (GAP)-Heart Failure (HF) project is designed to facilitate both inpatient compliance with American College of Cardiology/American Heart Association guidelines and transfer of the patient from the hospital to the primary care physician. Hospitals participating in the GAP-HF program are provided with the following menu of resources: an intervention toolkit including standing orders, nursing critical pathways, and a discharge contract; a physician–nurse team trained in guideline implementation to work with hospital clinicians and administrators; and a report card outlining each institution’s indicators of improved quality of care for heart failure. The Oregon Heart Failure Project The Oregon Heart Failure Project is a statewide effort aimed at improving the management of heart failure. This project was initiated in 2001 by the American College of Cardiology (ACC) as the ACC-HF-GAP program. In close partnership with the Oregon Medicare Quality Improvement Organization and The Robert Wood Johnson Foundation, the project was initially developed as a collaborative of cardiologists from diverse practice environments across a wide geographic area (the State of Oregon). Both the diversity and geographic dispersion of practice settings were intended to represent practice in the state. The project is focused on outpatient management and thus targets the majority of patients with heart failure—those not hospitalized. The project developed and tested a set of tools designed to make it easier to manage patients in the outpatient setting in compliance with the ACC/AHA guidelines. After establishing baseline data from all practices represented in the collaborative, the project is now poised to extend its work and disseminate its tools to the larger community of physicians and health systems that care for patients with heart failure in outpatient settings throughout Oregon.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities PAIN CONTROL IN ADVANCED CANCER COMMUNITIES Kaiser-Bellflower The Kaiser Permanente (KP) TriCentral Palliative Care Program, an interdisciplinary home-based program that blends palliative and curative care, offers patients at the end of life enhanced pain control, symptom management, and psychosocial support. It was developed for patients with congestive heart failure, chronic obstructive pulmonary disease, and cancer in response to KP internal data indicating that 63 percent of patients in intensive care units and 54 percent of other hospitalized patients with these diagnoses died. The program currently provides a gradual transition for patients with a 12-month survival prognosis, allowing them to maintain their primary care physician while receiving home visits from a palliative care team. The program has met goals for pain control, receives high patient satisfaction scores, and in an initial study was found to have reduced costs by 45 percent. The program is developing web-based resources for its replication; expansion to other KP sites is planned. Rochester Health Commission Rochester Health Commission (RHC), created in 1996, is a nonprofit, community-based organization dedicated to improving the quality, access, and cost of health care in the community. RHC was identified by the RAND Corporation as one of three model health care coalitions in the United States. Comprised of key stakeholders, the commission has equal provider, consumer, and business representation on its board. Currently, RHC has 12 communitywide initiatives under its umbrella, including those addressing patient safety, communitywide clinical guidelines, and end-of-life/palliative care. Communitywide clinical guidelines were developed for asthma, diabetes, depression, congestive heart failure, pain, and other conditions. The end-of-life/palliative care initiative focuses on improving pain management for all types of pain in all care settings, from doctors’ offices to nursing homes and hospices. RHC received a Robert Wood Johnson Rewarding Results grant for its work linking communitywide guidelines to incentives, and has long been involved in performance measurement, dating back to Health Plan Employer Data and Information Set (HEDIS)® reporting in 1999. RHC also developed the Rochester Model, a broad-based chronic disease proposal that focuses on restructuring the area’s health care system to properly align incentives and provider/consumer/employer efforts to improve health care.